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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801486
Report Date: 06/08/2022
Date Signed: 06/13/2022 09:59:13 AM

Document Has Been Signed on 06/13/2022 09:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AUTUMN MANOR, LLC #3FACILITY NUMBER:
565801486
ADMINISTRATOR:MARIA MENDEZFACILITY TYPE:
740
ADDRESS:2747 ATHERWOOD AVENUETELEPHONE:
(805) 527-8281
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria MendezTIME COMPLETED:
02:01 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 12:00 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Maria Mendez and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguishers appeared fully charged and were last inspected by the fire department on 06/16/2021.

KITCHEN: Knives were stored in a locked drawer and cleaning supplies were stored in a locked cabinet in the adjacent garage. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed one double-occupancy and three single-occupancy resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Restrooms are clean and sanitary and in operating condition.

COMMON SPACES: Living room and dining room furniture was observed to be in good condition. Required postings were observed throughout the facility. The patio was equipped with furniture for residents' use.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID. No deficiencies observed. Exit interview conducted. Report emailed to Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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